Original articleEstimating the costs associated with malnutrition in Dutch nursing homes
Introduction
A large number of patients in European healthcare organizations are malnourished.1, 2, 3, 4, 5, 6, 7 Therefore since 2005, the European Nutrition for Health Alliance has raised awareness of malnutrition as a significant public health problem that is extensively under-recognized and under-treated.1 Malnutrition (meaning undernutrition) is a serious burden, leading to increased mortality, longer hospital stays, more GP visits, more intensive nursing care, increased requirement of nursing home care, decreased quality of life and increased complication rates.3, 4, 5, 6, 7, 8 Both in terms of its impact on individuals’ health status and their increased needs for care and social services, malnutrition is a tremendous burden of illness in western societies, leading to costs of billions of euro’s every year.9
Quantifying this burden is a critical step in improving and completing our understanding of how malnutrition manifests itself amongst people of different age groups and clinical conditions. A small number of studies have assessed the economic implications of malnutrition related to hospital stay, residential care and community care. A UK study found that malnutrition costs £7.3 billion each year, more than double the projected £3.5 billion cost of obesity.10 The bulk of these costs arises from the treatment of malnourished patients in hospital (£3.8 billion) and in long-term care facilities (£2.6 billion). Other associated costs arise from GP visits (£0.49 billion), outpatient visits (£0.36 billion), and enteral and parenteral nutrition, tube feeding and oral nutritional supplementation in the community (£0.15 billion).10 The Erasmus MC University Medical Centre Rotterdam assessed the total additional health care costs of disease related malnutrition in the Netherlands roughly at 1.7million euro, using the prevalence of malnutrition as an indicator for calculating costs.11 This is equal to 2.8% of the total care costs in the Netherlands and 5.8% of the total costs in hospitals, care homes and home care.12 Despite this, no published studies exist, involving more precise economic implications of malnutrition in Dutch care homes.
In the Netherlands, long-term institutional care can be divided into residential homes and nursing homes. Residential homes (n = 1000) mainly offer assisted living (a safe living environment) to older people who are still able to do a considerable part of their ADLs themselves. In our study we focus on nursing homes. There are about 345 nursing homes in the country. Disabled persons with chronic somatic (i.e., physical) diseases or with progressive dementia, mainly elderly who are not able to do their ADLs and who need plural, more complex continuing care and monitoring, which are beyond the range of home care services or the service in residential homes, are often admitted to a nursing home. The nursing home sector has more than 60,000 beds. 27,000 beds in somatic wards, primarily for patients with physical diseases (e.g. stroke, other neurologic disorders like Parkinsonism and multiple sclerosis, problems affecting mobility and malignancies) and 36,000 in psychogeriatric wards for patients with dementia. Approximately 60,000 new patients (mean age 80 years) are admitted every year. Most of the somatic patients are admitted from the hospital (65%) or by their family physician (26%); psychogeriatric patients primarily come from their own home (53%), from a residential home (23%), or from a hospital (20%). Nursing homes employ their own multidisciplinary staff and this team consists, next to physicians and nurses, of physiotherapists, occupational therapists, speech therapists, dietitians, psychologists, social workers, pastoral workers, and recreational therapists.13
This study aims to determine the economic implications of malnutrition more precisely in nursing homes in the Netherlands, using the ‘bottom-up’ approach, in which costs of individual treatments, use of resources and the time spent on nutritional screening, monitoring and treatment of malnutrition are taken into account.
Section snippets
Materials and methods
In this study the economic costs of malnutrition were calculated for Dutch nursing homes by integrating 4 different approaches. For the calculation of economic costs, data were collected on time spent performing activities such as nutritional screening, diagnostics, monitoring, prevention, treatment, (multidisciplinary) communication and on which disciplines executed the activities (approach 1). To extrapolate these data, further data on at risk of malnutrition or malnourished prevalence
Analysis
Data gathered by these 4 different approaches were combined in one Excel file. Salary costs were calculated per discipline per minute since the information of the time spent to perform activities was registered in minutes. The minutes were extrapolated to years to get an overview on how many minutes per year an activity was performed per patient.
Prevalence rates of (risk of) malnutrition were derived from the LPZ 2009 database. Data on the total number of patients that were living in Dutch
Results
Twenty two dieticians, representing 110 nursing home organizations including 9855 patients (who were measured in the LPZ 2009 additionally), answered the questionnaire.
Furthermore, at the time of research a total of 60,000 patients are living in nursing homes in the Netherlands, of which according to the LPZ 30.4% were at risk of malnutrition and 20.3% were malnourished. 70% of the patients were mobile (walk frequently or occasionally) and 30% immobile (bed or chairbound).
In Table 1 the general
Discussion
Since 2005, the European Nutrition for Health Alliance (ENHA) has raised awareness of malnutrition as a significant public health problem because in daily practice this problem is extensively under-recognized and under-treated.1 In addition, the ENHA has conducted some studies related to the overall health economic impact of malnutrition in Europe. This study involves the Dutch part of the Health and Economic Impact of Malnutrition in Europe Study and the was the first study determining the
Conflict of interest statement & statement of authorship sections
J. M., R. H, L.W. and J. S. contributed to the design of the study. J. M., R.H. and J.S. helped in data collection. Data analysis was done by J. M., R.H. and J.S. The manuscript was written by J. M., R. H, L.W. and J. S. all provided significant advice or consultation. The final manuscript was approved by all authors. Furthermore we would like to state that there here was no conflict of interest and no further involvement.
Acknowledgements
The study is part of the Health and Economic Impact of Malnutrition in Europe study of the European Nutrition for Health Alliance. We would like to acknowledge the contribution of all experts like Professor Claude Pichard, Professor Olle Ljungqvist, Frank de Man, Suzanne Wait.
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